Resilience and Posttraumatic Growth

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Resilience and Posttraumatic Growth
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Resilience

• dynamic developmental process
• positive adaption
• despite adversity or trauma
• ? personality trait or attribute
• Two-dimensional construct
• Exposure to adversity
• Positive adjustment outcomes

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Posttraumatic Growth (PTG)

• growth process
• experienced positive change
• as a result of traumatic experience
• ? traumatic event itself, but aftermath
• Change beyond effective coping
• Beyond pre-trauma level of adaption
• Qualitative change across different domains

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Posttraumatic Growth
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Some changes associated with PTG

• Increased sense of personal strength
• discover new perspectives about relationships
• Identify salient characteristics in others
• (pos. and neg.)
• Modified priorities, shift in perspectives and
  value systems
• appreciate smaller things in life
• increased appreciation of life in general
• richer religious, spiritual, and existential
  lives
• (Calhoun Tedeschi, 2004 Tedeschi Calhoun,
  2004)

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PTG and posttraumatic stress symptoms

• Although benefits and positive change
• Still distress and struggle
• Less emotional well-being in individual reporting
  PTG (compared to resilient)
• contributes to growth process
• facilitates constructive cognitive processing of
  trauma
• Attempts to make sense of trauma and aftermath
• Productive ruminative process yields schema
  change
• Supportive others
• provide means to craft narratives
• offer new perspectives
• (Calhoun Tedeschi, 2004)

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Factors (potentially) affecting PTG

• Age (older)
• Gender (female)
• Severity and type of stressor/trauma
• Higher income
• More time since traumatic event
• Existential awareness (lifes fragility)
• Religiosity
• Higher levels of social support
• Calhoun Tedeschi, 1999, 2004 (Milam et al.,
  2004)

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Discussion

• Does this sound a bit like a cliché to you?

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• So, whats the evidence?

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Measures of PTG

• Qualitative (indirect) measures
• Secondary analysis of PTSD interviews
• Coding for elements of PTG
• (Salter Stallard, 2004)
• Quantitative measures
• For adults Posttraumatic Growth Inventory
  (Tedeschi Calhoun, 1996)
• PTGI-Revised for Children and Adolescents
  (Yaskowich, 2002)
• Posttraumatic Growth Inventory for Children
  Revised (PTGI-C-R) (Kilmer et al., 2009)
• Perception of Changes in Self scale (Kazak et
  al., 2001)

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Posttraumatic Growth Inventory for Children
Revised (PTGI-C-R)

• Kilmer et al. (2009), used with 7-10 year-olds
• Two open ended questions
• 10 items assessing PTG in five domains
• New possibilities
• Relating to others
• Personal strength
• Appreciation of life
• Spiritual changes

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Other measures for children and adolescents

• Posttraumatic Growth Inventory for Children
  (PTGI-C) (Cryder et al., 2006)
• 21 items from pool of 29 items (same five domains
  as PTGI-C-R)
• PTGI-Revised for Children and Adolescents
  (Yaskowich, 2002)
• 21 items (same five domains)
• Perception of Changes in Self scale (Kazak et
  al., 2001)
• 1 open-ended question
• 9 items

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Other measures for children and adolescents

• Secondary analysis of PTSD interviews (Salter
  Stallard, 2004)
• framework technique (Ritchie Spencer, 1994)
• Five steps (Familiarization, thematic framework,
  indexing, charting, interpretation)
• 3 areas of PTG
• Perception of Self
• Interpersonal relationships
• Philosophy of life

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PTG in children and adolescents

• Empirical studies with children and adolescents
• Milam, Ritt-Olson Unger (2004)
• Barakat, Alderfer Kazak (2006)
• Studies with young children
• Salter Stallard (2004)
• Cryder, Kilmer, Tedeschi Calhoun (2004)
• Kilmer et al. (2009)

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Adolescent with negative life events Milam,
Ritt-Olson Unger (2004)

• 435 adolescents (grades 9-12, m 15.8y)
• Predominantly Hispanic
• PTGI
• Negative life events (within previous 3 years)
• Closed-ended checklist of life change units,
  including 10 major neg. events (Coddington et al,
  1972)
• Common neg. life events
• Death of family member (34)
• Move to new home (16)
• Loss of close friend (11)
• Major illness to family member (10)
• Parents divorce/separation (10)

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Adolescent with negative life events Milam,
Ritt-Olson Unger (2004)

• Mean PTG score was 3.56 (mild amount)
• No different in PTG between types of events
• No different in amount of PTG for gender,
  ethnicity
• Correlations between PTG and
• Age ()
• Religiosity ()
• Substance use (-)

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Adolescent cancer survivorsBarakat et al. (2006)

• 150 adolescents cancer survivors (11-19 years)
• Hypothesis
• More time since, and higher perceived intensity
  of treatment more PTG
• Older age at diagnosis more PTG
• PTG Measure
• Perceptions of Changes in Self (PCS)
• Kazak et al., 1996, 2001

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Adolescent cancer survivorsBarakat et al. (2006)

• 84.7 of adolescents reported at least one
  positive consequence
• 53 think about life
• 42 plans for future
• 41 how careful
• 32 reported 4 pos. conseq.
• PTG and other variables (correlations)
• Age at diagnosis (), time since treatment (-),
  household income (n.s.)
• (perceived) past and current life threat,
  treatment intensity, PTSS (IES-R) (all
  correlations )

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Children in road traffic accidentSalter
Stallard (2004)

• 158 7-18y old children
• Secondary qualitative analysis of PTSD interviews
  (CAPS-C), IES
• 42 report PTG
• 37 of them also PTSD
• Mean age of children reporting PTG 16y
• Domains of PTG
• Perception of Self
• least applicable
• None used words survivor or victim
• Face reality of vulnerability

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Children in road traffic accidentSalter
Stallard (2004)

• Domains of PTG
• Interpersonal Relationships
• improved IR 12 general, 20 with people
  involved in accident
• Relationships closer cemented
• ? learning to disclose more about feeling, and
  ability to express more openly
• Philosophy of Life
• Most common theme
• Appreciation of life (31)
• Reevaluation of what was important (13)
• Feeling if there is something that you want to
  do, try do it- dont wait
• Few reports of a more relaxed approach to life

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Children affected by a natural disaster (Cryder
et al., 2004)

• Hurricane Floyd (Sept 1999)
• 1 year later
• Of 321 contacted only 46 (15)
• 6-15 years (m9.54y)
• 50 evacuated/displaced
• PTGI-C
• PTG score 37-84 (m65.11)
• Correlations with other variables
• Sign. corr. with competency belief
• No other sign. corr. (e.g. age, gender, severity,
  social support)

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Children affected by a natural disaster (Kilmer
et al., 2009)

• Hurricane Katrina (Aug 2005)
• T11y later, T22y later
• 68 7-10 year olds (m8.3y)
• Majority African American
• 73.5 prior Trauma
• PTGI-C-R (range 0-30)
• T120, T19.2 (50 avg., 10.6 little)
• No gender difference
• Correlations with other variables
• Sign corr. With subjective response to HK and
  PTSS (only PTSS in regression)
• No corr. with age
• T1 PTG only sign. predictor of T2 PTG

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Model of PTG in children(Cryder et al., 2004)

• Extended model (see Kilmer, 2005)

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Critique

• Hypothesized model
• Several factors remain untested
• Cryder et al. discuss link between PTG and social
  support (but no sign. Corr.)
• No control groups
• Normal developmental process?
• Positive bias

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A positive bias?

• N276 adults
• Two factors
• Exposure (to traumatic event)
• 42.5 exposure
• Method (PTGI)
• linked to stressful event
• not linked to specific event (generally past 4
  years)
• PTG higher in unlinked group (with event
  exposure)
• sign. Interaction exposure x method
• Suggests that growth underestimated, rather than
  inflated
• PTGI usually linked to specific event

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Development and PTG

• Cognitive maturity and psychological mindedness
• Interpersonal awareness and insight (Cryder et
  al., 2004)
• Affective quality of change and learning
• Response reflects dev. level/task
• Lieberman Van Horn (2004)
• Understand internalize depending upon
  cognitive/emotional capacities (Osofsky, 2004)
• Cognitive capabilities may influence
  understanding appraisal of trauma (Hasan
  Power, 2004)
• Attributions about circumstances
• Repertoire of coping skills/strategies
• Ability to marshal resources effectively
• Capacity to attend to and report internal
  experiences (Cryder et al. 2004)

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Development and PTG

• Possibly years before PTG (on some dimensions)
  manifests in children
• Positive relationship between age and PTG (Milman
  et al., 2004)
• Cognitive maturity necessary
• PTG process maybe qualitatively different in
  children
• Schemas not as clearly set in children
• New experiences incorporated into internal
  representations
• Children more vulnerable (Janoff-Bulman, 1992)

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Age and PTG

• Barakat et al. (2006)
• Age 5y at diagnosis as cutoff
• Age 5 shift in cognitive functioning, better
  process and reflect on their experiences
  (Alderfer et al., 2003)
• lt 5y fewer positive consequences
• Only 6.3 reported 3 positive changes
• In comparison 44 of gt 5y reported 3 pos.
  changes
• Childe age gt5y more PTSS
• But sign. Correlation between PTG and PTSS in
  both gt5y and lt5y

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Relevant research areasTheory of mind (ToM)

• Understanding of own and others mental states
• Desires, beliefs, emotions, intentions
• Important area in developmental psyc
• Age 5y important shift in development

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ToM Belief-based emotions (Harris et al., 1989
Sprung, 2008)
gt5y
Which one do you like the most?
Later youll get whats in this box. So, put the
one you like the most in the box.
doll
Which one do you like the least?
sponge
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ToM Belief-based emotions (Harris et al., 1989
Sprung, 2008)
? ?
gt5y
Now, lets work on another task and later you
get whats in the box.
How do you feel now, about whats in the box?
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ToM Belief-based emotions (Harris et al., 1989
Sprung, 2008)
? ?
lt 5y
Whats in the box?
Before you open the box, how did you feel
How do you feel now?
What did you think is in the box?
doll
Very good, now you get whats in the box.
sponge
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ToM Introspection(Flavell et al., 1995)
lt 8 years
No thoughts
easy having no thoughts
While you where sitting in the no thinking chair,
did you have no thoughts or did you have some
thoughts?
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Theory of mind

• Not mentioned in literature on PTG
• Although Kilmer mentions psychological
  mindedness
• Theory of mind and Trauma
• More advanced ToM more reports of PTSS Sprung
  (2008)
• PTG not assessed

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Other relevant research areasinternal working
models

• John Bowlby
• Attachment theorist (strange situation)
• First caregiver-child, later extended to other
  people/situations
• Also not addressed in PTG lit.

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Vulnerability versus protection

• Basic assumptions (safety, protection from harm,
  predictability) violated (Goldman, 2002)
• Loss of trust, meaning, faith
• Formation of traumatic expectation distorting
  (Pynoos et al., 1995)
• Emotional, cognitive, moral concepts
• Inner representations of self, object relations,
  social environment
• Disrupt sense of self/others, emotion regulation,
  explorative learning (Lieberman Van Horn, 2004)
• Trauma in infancy/early childhood derails
  normative developmental course
• (Lieberman Van Horn, 2004)
• Pynoos (1990)
• Difficulties in multiple domains (Bosquet, 2004)

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Vulnerability versus protection

• Childrens basic assumptions less firmly
  entrenched/embedded
• Open to adaptive inputs
• Protective
• Factors to help buffer against traumatic impact
• Emotional caring/interpretive effort of others
  (especially parents)
• Supportive environment for child to attempt
  understand, incorporate
• Input of others can guide interpretation,
  reframe, transform
• (Janoff-Bulman, 1992)

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Discussion

• Do you think PTG in young children is possible?

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• Some problems
• Extend of literature (two fields clin. and dev.)
• Dev. lit childrens understanding quite
  sophisticated
• struggle about similar issues
• But limitations (e.g. introspection)

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PTG reality or illusion

• Real vs. illusory process (Sumalla et al, 2009)
• Real (positive) identity change
• Illusory process
• Coping strategy

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Resilience
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Three facets of resilienceLepore Revenson
(2006)

• Recovery
• Tree will bend to accommodate wind, so it wont
  break, and will return to upright position when
  wind stops
• Resistance
• Tree stands still, undisturbed, in face of
  howling wind
• Reconfiguration
• Tree not simply make temporary accommodation,
  then resume original shape
• instead, it changes its shape (making it more
  resitant to break in future winds)

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Three facets of resilienceLepore Revenson
(2006)

• Recovery
• Stressor disrupts a persons normal state of
  functioning,
• When stressor passes, person resumes her normal
  pre-stressor level of functioning
• Resistance
• People who exhibit normal functioning before,
  during, and after a stressor (even long after a
  stressor)
• Reconfiguration
• Individuals reconfigure their cognitions,
  beliefs, and behaviors in manner that allows them
  to adapt to traumatic experiences
• Possibly withstanding future trauma

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Discussion

• Whats normal response following traumatic event?
• E.g. loss of a loved one

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Resilience an ordinary phenomena(Masten, 2001)

• Originally (1970s) something special, remarkable
  about resilient children (invulnerable)
• But ordinary phenomenon
• Common operation of basic human adaption systems
• If major systems intact function well
• If impaired, adversity risk

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Two kinds of judgments

• (1) Threat (Not resilient, if no threat)
• Risks, such as low SES, negative life events,
  community trauma, etc. (also cumulative)
• Co-occur with psychosocial competence,
  psychopathology, health
• Risk gradients can be inverted to assets or
  resources
• Pure risk car accident, pure asset talent or
  friend
• Mostly pos. and neg. end
• e.g. good parenting vs. poor parenting
• Competent parents produce fewer stressful fam.
  life events (risks), choose to live in
  neighborhoods with low crime (risks), good
  community resources (assets), more likely to hire
  tutors (assets)

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Two kinds of judgments

• (2) Quality of adaption or dev. outcome assessed
  or evaluated as good or OK
• (a) Meeting major expectations of a given society
  or culture (salient developmental tasks,
  competence criteria, cultural age expectation)
  (Elder, 1998 Masten et al., 1998)
• (b) Absence of psychopathology or low level of
  symptoms and impairment (Tiet et al., 1998)
• (c) Both ab (Greenberg et al., 1999)

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Related question

• External adaption criteria
• Accommodation, achievement, absence of
  delinquency
• Internal
• Psychological well-being, low level of distress
• Or both
• (Luther et al. 2000)

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Historical overview

• Atypical schizophrenics (Garmezy, 1970)
• Children from mothers with schizophrenia
  (Garmezy, 1974 Masten et al., 1990)
• Emmy Werners groundbreaking studies with
  Children in Hawaii (Werner et al., 1971 Werner
  Smith, 1977)
• Studies of multiple adverse conditions (search
  for protective factors)
• Low SES
• Parental mental illness
• Urban poverty
• Community violence
• Chronic illness
• Catastrophic live events

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Models/approach to resilience(Masten, 2001)

• Variable focused
• Link among measures of degree of risk/or
  adversity, outcome, potential quality of
  individual or environment (to compensate/protect)
• Person focused
• Compare people with different profiles (within or
  across time) on sets of criteria to ascertain
  what differentiates resilient from non resilient
  children

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Variable focused studies

• Compensatory effects
• Enough positive assets could offset the burden in
  childs life from one or many risk influences
• Three models
• Main effect
• Indirect
• Interaction

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Variable focused studies

• Main effect models

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Variable focused studies

• Indirect models (example)

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Variable focused studies

• Interaction models

• Not found very often (difficult to detect)

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Variable focused studies

• Factors emerging
• Parenting quality
• Intellectual functioning
• SES
• Positive self-perception
• Broad, pervasive corr. with multiple domains of
  adaptive behavior

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Person focused studies

• Single case studies (Masten OConnor, 1984)
• Groups of individuals with patterns of good
  versus poor adaptive functioning (in context or
  high vs. low risk/threat)
• Two groups from same high-risk groups (Werner
  Smith, 1982 Cowen et al., 1984)
• Low risk groups
• Variety of stress-affected and
  stress-resilient

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Person focused studies

• Emerging profile (Masten, 2001)
• Average or better competence on three salient
  domains
• Academic
• Conduct
• Social
• Resulting in similar psychosocial resources
• intellectual functioning
• Parenting quality
• Positive self-concepts

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Pros and Cons

• Variable focused
• Max. stats power, suitable for searching
  specific links between predictor and outcome
• - Fail to capture striking patterns in lives of
  real people, risk of losing sense of the whole
• Person focused
• variables assembled in naturally occurring
  configuration, well suited for search for common
  and uncommon patterns in lives
• - Can obscure specific linkages

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Positive Psychology

• The role of positive emotions
• Fredericksons broaden-and-built theory
• More positive emotions more resilient?